Amanda Glassman slams an Oxfam report criticising a World Bank-supported health insurance programme in Ghana.
A March 2010 quasi-experimental impact evaluation by Joseph Mensah and colleagues finds that women who are health insurance beneficiaries are much more likely to give birth in a hospital, be attended by a trained professional at birth, receive pre-natal care, experience fewer birth complications and fewer infant deaths. Never mind that Mensah is a professor at York University and has a good quality data set in the UNICEF-sponsored 2008 Multi-Indicator Cluster Survey. Never mind that the purpose of an impact evaluation is to illustrate the results of an intervention in comparison to a counterfactual (i.e., no insurance – the state that Oxfam thinks Ghanaians should go). See here.The report was touted by the Guardian's Poverty Matters blog, which does offer a comment from a World Bank representative, but still implicitely gives a lot of weight to the Oxfam report, despite its flaws.Although Oxfam reports that only 18% of the population is enrolled in the insurance scheme, the nationally representative 2008 Demographic and Health Survey reports that 39% of women and 30% of men ages 15-49 report that they are enrolled in the insurance scheme. If we count their children, the proportion of the population covered increases substantially. About 90% of both groups report having a card. Unsurprisingly given that formal sector employees are automatically enrolled based on their salary contributions, about half of insurance enrollees are in the top two wealth quintiles while the other half are below the poverty line. Eighty-two percent of beneficiaries report that they were satisfied with the quality of service. While it is not possible to establish causality using the descriptive data from the DHS, the pace of under-5 and neonatal mortality decline has accelerated since 2003 (introduction year of insurance) when compared to the 1998-2003 period.
This isn't the first time Amanda has jumped on a piece of sketchy research that was picked up by the media - a few months ago she joined me in criticizing an Oxford study and subsequent Guardian article which suggested the IMF was suppressing health spending in recipient countries.
Why aren't these reports critically appraised more often given they are so often deeply flawed? For journalists, it is always easier to highlight the results of the study than to try and determine their limitations, an exercise which is usually pretty ill-suited for a simple blurb in the newspaper. The typical academic is far too busy trying to keep his/her head down on the long march towards tenure (or attending yet another committee meeting) to start a turf war with other academics and institutions - we prefer to confine the bickering and grandstanding to the lecture room.
There are, of course, researchers working for big development institutions who have a bit more freedom to go on the attack, but often only when someone releases research that contrasts disagrees too sharply with their own world view. One exception is the presence of think tanks like the CGD, which house experts who feel free enough to critically examine popular institutions like microfinance and the Millenium Villages, but these are unfortunately far too infrequent.
So, who is ready to start a think tank with me dedicated solely to criticism? Maybe it's time to start a Nobel prize for shooting down bad ideas.
6 Comments
You got some funding yeah? Or maybe we could set up a commercial enterprise: "We trash your report"TM.
"So, who is ready to start a think tank with me dedicated solely to criticism?"
Isn't that the DRI?
I meant accessible criticism
Dear Matt
I am not sure you have seen the detailed response from partners to the CGD blog by Amanda and by Patrick Apoya who did the research. Both her's and your representation of the report appear to ignore some key points. Most critically the report is very clear why it does not use the Demographic and Health survey as the information on card ownership is not clear.
Also saying that those with insurance receive better care completely misses the point, as no one is disputing this. The point is that many people, and predominantly the poorest are excluded from this coverage, despite the fact that they all pay for it through VAT, a double inequity. The Ghana health system is in fact a tax financed system, not a premia funded insurance scheme, so it is good healthcare paid for by the many and accessed by the few.
I have a lot of respect for what CGD produces, but a balanced critique this is not, nor should it be represented as such.
The response from partners is copied below for your readers.
Cheers Max
In your criticism you seem to have missed some of the central messages and evidence in our paper, which should be clarified. The report was a joint effort of Ghanaian NGOs, including ISODEC, Alliance for Reproductive Health Rights and the Essential Services Platform of which I am the Convener, as well as Oxfam. I have worked to monitor the progress of our health sector for some time now whilst our organisations are dedicated to protecting the right to health for all Ghanaians. The paper was motivated first and foremost by a collective of concerns of the organisations involved about access to and equity of health care in Ghana. I hope you agree that it is important for Ghanaian civil society to have a voice and whilst we are open to evidence based criticism, your approach seems more focussed on point scoring at the expense of the serious concerns we have raised about the fairness our National Health Insurance Scheme. For the benefit of your readers I would like to clarify a few of the things you have missed and potentially misunderstood. The paper is clear that the NHIA was a welcome and progressive step towards improving access and ‘recognised the detrimental impact of user fees and the fundamental role of public financing in the achievement of universal health care’. The paper was also clear that for its members the NHIS has brought benefits. Benefits include a higher rate of attendance; better financial protection, as well as the very positive impact on health outcomes for pregnant women in the study to which you refer. Do note however that the benefits you cite for pregnant women are thanks to the government decision in 2008 to make their membership to the NHIS automatic and free. On the other hand NHIS coverage has been hugely exaggerated and the majority of citizens are not enjoying these benefits despite paying for the NHIS with their taxes. The NHIA has conceded in the latest independent review of the health sector and in their own annual report that their coverage data is an accumulation of all those ever registered with the scheme – not those with a valid membership card at any one point in time. You seem to have missed the clear explanation of why the 2008 household survey cannot be relied upon – not due to poor methodology but due to the fact that at the time it was impossible to distinguish between a valid and an expired membership card. We are transparent about the methodology we have used to arrive at the 18% coverage estimation and welcome the NHIA challenging this estimate with evidence based figures. Your response appears to condone the status quo while ignoring many of the problems with the current system including unsustainable cost escalation, inefficiency, poor transparency, fragmentation but most importantly the fact that the majority of Ghanaians excluded from the scheme cannot afford to pay the insurance premium on top of the taxes they already pay. In this context your call to the government to enrol more members seems a little simplistic. You assume that Ghana does not have the fiscal resources to extend access and perhaps you also missed this point in our paper. With efficiency savings, an improvement in the quality of aid, but primarily through improved progressive taxation of Ghana’s own resources we have estimated that per capita health spending could increase by 200% by 2015. Thank you for your suggestion but Ghanaian civil society is not willing to settle for a reduced benefits package when our government can afford to deliver a comprehensive benefits package to all. In the paper we congratulated rather than condemn the Government of Ghana for their commitment to health but say that much bolder steps are now required to implement their own commitment to deliver free health care for all. We are optimistic that our engagement with the government going forward will be productive in pushing through the necessary changes to achieve our shared national goal of universal health care.
In case you haven't seen it, here is a good, solid and measured response to not very good, solid or measured criticism that you joined in with:rnhttp://www.oxfamblogs.org/fp2p/?p=4868
Paul -nnThanks for the note, if you go up to this post: /ghanaian-health-care-cage-match/ already a few days old, you'll see that I'm very much aware of Duncan's post.